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Shining a light on surgeon burnout is vital to doctors' health, patient safety

Thursday, March 31, 2016

Many young surgeons aspire to a career like that of C. Scott Hultman, MD, MBA, Chapel Hill, N.C. He's Plastic and Reconstructive Surgery division chief and professor of Surgery at the University of North Carolina, associate director of the avid researcher. Away from work, he and his wife enjoy a solid marriage with three great kids. associate director of the N.C. Jaycee Burn Center and an avid researcher. Away from work, he and his wife enjoy a solid marriage with three great kids.

Internally, however, Dr. Hultman admits that he's struggled with "physician burnout" in the past. It's a condition that manifests in different ways and impacts scores of plastic surgeons – but it's a topic rarely broached beyond medical literature.

"For me, I don't get depressed or sad; rather, I can become irritable and more easily frustrated," he tells PSN. "I know when burnout affects me, because I can't sleep through the night – I find myself waking up before the alarm goes off, wondering how I'll complete all the day's activities. I've also become susceptible to migraines, and while not incapacitating, they often occur with moderate nausea. I don't operate when I have a migraine.

"I'm not afraid to say there have been times when I've taken medication to help me sleep, because sleep is critical for daily focus," Dr. Hultman adds. "I'm also at an age, 51, where anxiety can interact with one's physical health and affect blood pressure."

Definitions of physician burnout vary, but according to the widely accepted Maslach Burnout Inventory – an assessment tool developed by social psychologists Christina Maslach and Susan Jackson – it's considered to mainly present itself in:

Emotional exhaustion: feelings of being emotionally overextended, depleted and exhausted by one's work

Reduced personal accomplishment: lessened productivity or capability, low morale, social withdrawal and an inability to cope

Burnout symptoms can include anxiety, anger, chronic sadness, substance abuse, failing relationships and self-destructive behavior. Studies abound concerning the rate and depth of the condition, with one recent article revealing that physicians experience burnout at a rate twice that of the general population.

Burnout also has its own ICD-10 code – Z73.0 – with its "approximate synonyms (of) physical and emotional exhaustion state," found under the heading "Problems related to life-management difficulty."

Physician burnout can carry its negative effects into the clinic and O.R., bringing patient safety into the picture. "The potential ramifications of physician burnout include suboptimal patient care, decreased patient satisfaction, increased rates of medical errors and increased medico-legal litigation," note the authors of the study "Burnout Phenomenon in U.S. Plastic Surgeons: Risk Factors and Impact on Quality of Life," conducted by members of the Division of Plastic and Reconstructive Surgery at Northwestern University's Feinberg School of Medicine and published in the February 2015 issue of PRS.

To be a physician openly diagnosed with burnout is to be, at the very least, exposed to second-guessing by the general public on the wisdom of continuing his or her practice; colleagues, too, may look down upon this type of revelation, which further exacerbates the problem and allows it to proliferate unchecked.

"When I think about others who might be suffering in silence, I'm encouraged to speak up, because I've witnessed extreme burnout in some of my colleagues," Dr. Hultman says. "They need to know that it's OK to talk about this. A physician who's struggling with burnout may not be aware of its impact on his or her practice and personal life. Physicians with burnout may generate increased patient complaints and commit medical errors – but these don't have to happen.

"Burnout is now recognized as a reaction to the increasingly complex environment in which we practice medicine, where administrative demands, electronic medical records and governmental regulation can drive a wedge between the patient and the doctor," Dr. Hultman says.

"The sheer joy of helping a patient can be overshadowed by all of these stressors, which is how burnout starts," he adds. "Physicians may begin an insidious path that leads to disruptive behavior, affective disorders and substance abuse. As a surgical educator at an academic medical center, I know this condition is growing and, more importantly, that help is out there."

ASPS President David Song, MD, MBA, who's witnessed the negative effects of burnout as it insinuated itself into the lives of his colleagues, advises anyone who thinks they're immune to burnout to undergo an immediate "reality check" – because chances are, burnout is coming for them, as well.

"Get over the denial that it can't happen to you – it can," says Dr. Song. "And it's happening with increasing frequency."

A study on burnout in the medical profession by the Mayo Clinic and AMA ("Changes in burnout and satisfaction with work-life balance in physicians and the general U.S. working population between 2011 and 2013") notes that its results suggest "burnout may erode professionalism, influence quality of care, increase the risk for medical errors and promote early retirement. Burnout also seems to have adverse personal consequences for physicians, including contributions to broken relationships, problematic alcohol use, and suicidal ideation."

The stakes are clearly high.

"If I can prevent one physician from harming a patient or harming themselves because they've read this and decided to see a mental health professional or get on medication because of my story," Dr. Hultman adds, "then it's all worth it. No question."

'It's happening to everybody'

"American medicine is at a tipping point" due to rapidly rising rates of physician burnout, according to Tait Shanafelt, MD, the lead author of the Mayo Clinic/AMA study that reveals a 10 percent increase in burnout over the last three years alone.

"This (burnout) is happening to everybody," says ASPS Vice President of Education Jeffrey Janis, MD, who's spearheading an effort to bring physician burnout – as well as its counter, physician wellness – into the light through special programming later this year at Plastic Surgery The Meeting in Los Angeles.

"The topic of burnout hasn't yet become accepted 'water cooler conversation,' so physicians don't want to feel as if they're the only one in the room with the condition," says Dr. Janis, who's a professor of Plastic Surgery, Neurosurgery, Neurology and Surgery, and chief of University Hospital at Ohio State University. "When we find out that many, many others are experiencing burnout or something close to it, we'll finally understand that it's more prevalent than we think. Then it'll become an open conversation – but we need to hasten that conversation."

Dr. Janis admits that he's not immune to burnout. "I found myself entertaining the question of 'Am I the only one feeling this pressure, this stress?'" he says. "People don't talk about this, and someone needs to break the ice – everybody in medicine is feeling this."

ASPS member Jesse Selber, MD, Houston, who recently made news for leading the first skull-and-scalp transplant last May, says high levels of achievement and recognition are no salve for physician burnout, which for him is exacerbated, if not created, by an overabundance of professional stress.

"I don't know what the average plastic surgeon experiences regarding stress, but I know that I experience a tremendous amount," he says. "It's a constant battle – but it's partially due to the lifestyle I choose to lead. The volume and array of things I do, in the environment in which I do them, with the accompanying intensity and for what rests on my shoulders, would cause most people to curl-up in a fetal position."

Dr. Selber, director of Clinical Research and associate professor in the Department of Plastic Surgery at the University of Texas MD Anderson Cancer Center, shares the opinion that physician burnout needs to be addressed – now.

"This topic is really important – and way underreported," he says. "I've dealt with the acute stress-response to specific events, such as rapid heart rate, feelings of panic. To some degree I've experienced those all my life, but they're certainly made worse by the overall feeling that my work burden is somewhat out of control. The underlying feeling that 'I have too much to do' sort of makes me feel miserable; it sucks the joy out of things because it casts a pall over whatever else is happening.

"I've found that where the more youthful version of myself was more fun-loving, carefree and spontaneous, my slightly older version is more crabby, laden with responsibilities and slightly less-willing to take risks," Dr. Selber says. "I do have panic attacks, but I've always had that. I'm a microsurgeon so I have back pain, which I've struggled with for a couple of years. Then I'm tired a lot – but I have trouble sleeping. All of it has gotten worse over the years. It's a lovely picture, isn't it?"

"Being in an academic center I've had mentors of all specialties," says Dr. Song, vice chairman of the Department of Surgery and chief of the Section of Plastic and Reconstructive Surgery at the University of Chicago School of Medicine. "I've seen firsthand physicians' diminishing levels of patience, I've seen joylessness and definite depression – and then I've watched as they've become withdrawn.

"I've seen the end signs of burnout, too, and it's alarming," he adds. "These are the leaders who presumably know better than us about medicine – yet they were unaware of, or not acknowledging, a condition that bore down on them relentlessly. Even today I see faculty members fall into this spiral."

Burnout by the numbers

This apparent epidemic of burnout is slowly, steadily and, perhaps most alarming, silently hitting U.S. physicians. The Mayo Clinic/AMA survey reveals that 54 percent of the 7,000 physician respondents experienced at least one symptom of burnout within the previous 12-month period. That demonstrated a rise of 10 percent since a similar survey conducted three years earlier, the survey noted.

The Northwestern study, which focused solely on plastic surgeons, revealed that nearly 30 percent of the respondents fell into the "validated" burnout category, with one-fourth having "significantly lower quality-of-life scores than the U.S. population norm ... (as well as) lower career satisfaction and more work/home conflicts." Respondents also "had a nearly twofold increased risk of self-reported medical errors and self-reported impairment."

The Medscape Physician Lifestyle Report released in December 2015 reveals an overall physician self-reported burnout rate of 46 percent, with critical care and emergency medicine physicians exhibiting the highest percentages (53 and 52, respectively). In that study, plastic surgeons ranked near the middle (16th out of 26) at 45 percent, but third in terms of severity, trailing only nephrology and cardiology.

In the article "Being Well and Staying Competent: Challenges for the Surgeon," the American College of Surgeons (ACS) revealed findings of surveys in 2008 and 2010 that show 40 percent of respondents "met diagnostic criteria for burnout; 30 percent screened positive for depression; only 36 percent felt their work schedule left enough time for personal and family life."

According to the AMA, the problem of physician burnout is an issue that must first be acknowledged – and then mitigated as soon a possible. "Modern medicine can take a toll over time," AMA President Steven Stack, MD, says. "The AMA wants physicians to know of risks associated with burnout and strategies to combat it."

And far from being temporarily shielded from the elements that lead to the burnout of their older colleagues, younger physicians are also experiencing burnout in rising numbers, with one analysis of a study conducted by the University of North Carolina calling it "an epidemic" with 70 percent of UNC residents qualifying as "burned out."

What's behind it?

The reasons behind this build-up of burnout are both varied and still under examination; in many cases, they are subjective. Research by AMA Vice President of Professional Satisfaction Christine Sinsky, MD, has shown elements of physician burnout linked directly to the use of electronic health records (EHR).

"The technology can help physicians and their teams care for their patients, but it's also been a significant source of stress and burnout for physicians," she says. "In large part, that's due to work previously done by others being transferred to physicians; new work that's been generated by the EMR; and that it often takes much longer to do the same tasks with an EHR. It takes three seconds to orchestrate the next steps of care for a patient using a paper visit-planner; to do the same work in the EHR takes more than two minutes. Multiply that by more than 100 patients a week and docs are spending a lot of time they hadn't before doing data entry."

In other words, physicians spend less time being doctors and more time with their heads buried in a laptop, checking boxes and punching in numbers.

Dr. Song sees multi-factorial elements at work, including several unintended consequences of health-care reform, and time constraints that weren't present a generation ago. "Health-care reform is putting pressure on physicians to make them prioritize productivity over, potentially, patient care; many of us are being asked to do more with less," he says. "And the luxury of taking time with your patient is quickly fading."

Dr. Song also suggests another possible factor is linked to a perception that the level of respect afforded to physicians is diminishing. "Nowadays people are like, 'You're a doctor? Why aren't you in finance instead?' Between that attitude and Google – which turns many patients into 'wannabe doctors' – physicians are being subject to chronic irritants," he says. "The days of 'doctor knows best' have become 'Google knows best.' But patients don't take the time to understand that Google didn't go to medical school."

The study of plastic surgeons by Northwestern identified several risk factors for burnout, including work hours, call burden, subspecialty choice, control over work schedule, reimbursement schedule, work-family stressors, age and gender. It added, however, that burnout within the specialty had yet to be evaluated on a large scale.

An article in the ACS Bulletin in June 2013 pointed to "preexisting psychological characteristics" that predispose physicians to burnout, including that surgeons "are trained never to make a mistake, so when they do, the surgeon may be tormented by his or her own sense of perfectionism, resulting in self-incrimination and even self-loathing... Unfortunately, some surgeons are unable to differentiate perfection from the aspiration to excel."

The article added that due to the perfectionism characteristic, surgeons are beset by "numerous cognitive distortions: that they're valued only for their performance; that the better they do, the better they are expected to do; and that, if they lose the 'edge,' they will lose colleagues' support."

'Just suck it up'

William Norcross, MD, Physician Assessment and Clinical Education (PACE) director at the University of California-San Diego, runs a program that addresses the overall health and wellness of physicians, including working with medical professionals who deal with such issues as substance abuse and physical struggles.

He's seen a variation of the "expectation mindset" firsthand, as a medical student in the mid-1970s – where he was exposed to what he terms "the hidden curriculum" that shapes surgeons and retains a negative influence throughout their careers. He notes that it still exists in some form today.

"We were on call five of seven nights and working 120 hours a week – and we were just supposed to deal with that," Dr. Norcross says. "We were expected to 'work hard and suck it up.' We were subjected to verbal abuse, but we were also expected not to whine. It was never brought up in a classroom, it was never told to me that you just work very hard and deprive yourself of sleep, and then, if you do burn out or become depressed, you just suck it up and don't deal with it. But sometimes the consequences of that are fatal.

"I've recently heard academic leaders talk about 'weak medical students, strong medical students, weak residents, strong residents," he adds. "Some may be in reference to medical ability, but just the fact that the adjectives used are 'weak' and 'strong' is part of the inference, the culture, that we'll be strong, we'll be tough, we won't complain."

That culture, while showing signs of fading, still exists, Dr. Norcross says. "There's a cumulative build-up of stressors that will have a destructive effect upon physicians, and we're seeing that."

"We harm ourselves as a group; we're not particularly good to each other," agrees Dr. Selber. "A lot of the stress created in our lives is a product of the lack of collegial relationships with the people around us. If we took care of each other as a group, particularly at work – were we more understanding and less competitive, more supportive and collaborative – we might function much better."

"Part of this growing problem is the attitude of physicians themselves," Dr. Norcross adds. "Physicians choose to suffer in silence, to not complain; they choose to be 'supermen' and 'superwomen,' which often leads to a benign but very real type of denial," he says. "They must be aware of and acknowledge their burnout before it can be solved."

Add to the mix of these myriad stressors the demands that come with being a young parent, and the combination is even greater pressure, says ASPS Vice President of Research Andrea Pusic, MD.

"Looking back, there were many times that I felt the need to be in two places at once – such as in clinic and with my child, who was young at the time – and that pressure was on top of all the other pressures that came with being a plastic surgeon," Dr. Pusic recalls. "I remember thinking: 'I should just give this up; I can't do this.' And nothing's really changed since then. Stress remains an unsolved problem. In the culture of plastic surgery, I don't think we've done a good job of addressing stress."

"Many colleagues who, maybe 20 years ago, could go home and have dinner with their children are routinely not home for that today," Dr. Songs adds. "They're doing more, and they finally get caught up in this gerbil-wheel of work that eventually becomes self-perpetuating until they suddenly stop and ask: 'Why am I so stressed?'"

The tasks

Dr. Hultman says a never-ending list of responsibilities and seemingly infinite supply of non-surgical tasks ratchet-up his stress levels. "It's the administrative workload," he says. "I love managing and leading a plastic surgery division, but things such as investigating an H.R. problem among my staff – or finishing one task only to find two more in my in-box – those make me frustrated and stressed. I can never seem to whittle that list down."

Ironically, when that list or his schedule requires no action in any given moment, instead of feeling relaxed, Dr. Hultman feels even more stress. "If I'm in a moment where I don't have anything going on, that's when I become the most anxious," he says. "My mind drifts to the list and the things I've got to get done."

While many surgeons say the O.R. is where they feel most relaxed, it's not always a refuge for all. For Dr. Selber it can be a contributing factor, due to the nature of some of the procedures he undertakes.

"If there are surgeries that I do in which they aren't completed properly, the person doesn't get off the table alive," he says. "The skull/scalp transplant is an example, but there are many cases where success is absolutely required for the continued survival of the patient; 'failure is not an option.' That's the definition of a stressful environment. It's not like performing a facelift or a breast aug, not to disparage those procedures. They're an important part of the specialty, but they don't incur the same kind of stress load as the live-or-die scenarios.

"I also feel very connected to the patient outcomes, not just for my own performance but for their long-term quality of life," Dr. Selber adds. "There's a lot riding on all of it. Surgery is enjoyable and challenging, but for me it's certainly no sanctuary from stress."

Dr. Janis says he recently found himself referencing "The Seven Signs of Burnout" (see box at left) and was shocked at what he found. "I went through all of these, and truth be told, I had all seven," he says.

"I work in a large academic institution and always have – I've never known otherwise – but I'm certainly not my own boss," Dr. Janis says. "I've always felt there was this vice, this pressure that was constantly being applied to all of us to generate more RVU productivity, publish more papers, give more lectures at CME meetings."

Add to that "citizenship" requirements, time spent volunteering on university or department committees and task forces, and time becomes a premium.

"I moderated a panel in 2014 at the AAPS meeting where I heard University of Wisconsin Plastic Surgery Division Chief Michael Bentz, MD, deliver a lecture on work/life balance, which he gave from a personal standpoint," Dr. Janis recalls. "He asked his daughter for her help and perspective, which was a brilliant request. The upshot was that when you say 'yes' to something, you say 'no' to something else – which often is your family.

"All of these points on a curve spell-out a warning that reads: 'Get work/life balance before it's too late,'" Dr. Janis says.